Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections associated with intensive care units (ICUs) (Blot et al., 2011). The incidence rates of VAP are correlated with the risk profile of patients and the duration of their exposure to mechanical ventilation. The systematic review conducted by Blot et al. revealed that rate of VAP for patients exposed to the artificial ventilation was 9.7 % (Blot et al., 2011). VAP seriously increases the rates of morbidity and mortality while adding to the hospital costs and making ICU length of stay longer by 4 to 10 days (Blot et al., 2011). The systematic review showed that some studies assess mortality rates attributed to VAP in the range from zero to fifty percent (Blot et al., 2011). The following issues might play a role in the negative health outcomes: causative microorganisms, inadequate antimicrobial therapy, nursing guiding protocols and following the instructions of the Surviving Sepsis Campaign (Blot et al., 2011). This paper will analyze the article titled “Patient to Nurse Ratio and Risk of Ventilator-Associated Pneumonia in Critically Ill Patients” written by Blot et al. (2011) and will summarize its importance for the minimization of nosocomial infection rates and the nursing profession.
The quality of the health care outcomes could be significantly improved if VAP and its dangerous consequences became a focus of extensive studies. The exploration of the issue and the collection of knowledge about this type of pneumonia along with the implementation of new care protocols could substantially minimize the risk of the disease occurrence (Blot et al., 2011). However, even if new protocols are developed it is difficult to ensure their implementation considering the current staffing levels of ICUs. Extremely high workloads and a shortage of qualified practitioners have been shown to have a negative influence on the quality of care (Blot et al., 2011). Epidemiological cohort studies also revealed that low patient to nurse ratio is associated with health care professionals not following hand hygiene guidelines and high rate of medical errors (Blot et al., 2011). The study described in the article aimed to explore the “relationships between nurse staffing levels and the risk of VAP in patients treated with mechanical ventilation” (Blot et al., 2011).
Research Design, Materials and Methods
EU-VAP/CAP was designed as prospective, multicenter, observational study. It was conducted in the following European countries: Belgium, France, Germany, Portugal, Spain, Turkey, Greece and Italy (Blot et al., 2011). The study included patients from 27 ICUs who were either receiving mechanical ventilation or needed an admission for pneumonia diagnosis (Blot et al., 2011). Their admission diagnoses were not taken into consideration; therefore, initial cohort consisted of all individuals in ICUs with potential pneumonia. Information about socioeconomic status, primary diagnosis and duration of stay in ICU was collected. In order to classify underlying disease, McCabe scale of comorbid conditions was used (Blot et al., 2011). According to it, all prognoses for patients’ chances of survival from an underlying disease fell into 3 categories: 5 years, 1 to 5 years and less than 1 year (Blot et al., 2011). In order to assess the patient’s prognoses of survival from an acute disease, the Simplified Acute Physiology Score (SAPS) II was used. It allowed assessing the following factors: admission type, patients’ chronic diseases, age, temperature, liver tests, urine output, white blood cell count and a score on the Glasgow Coma Scale (Blot et al., 2011). Paper-based report forms were used to collect the data. Later, all information was examined for inconsistencies and entered into an electronic database.
After the exclusion of information regarding pneumonia patients in ICUs that did not indicate their staffing levels, study group consisted of 1658 patients receiving 48 hours of mechanical ventilation was chosen(Blot et al., 2011). The sample size was adequate and was fitted the objective of the study. It can be said that its magnitude was sufficient enough to present a scientific significance. Moreover, the population chosen for study was selected appropriately considering that patients with either previous pneumonia diagnosis or pneumonia that is not associated with artificial ventilation were not included in the sample (Blot et al., 2011). It can be argued that a significant limitation of the study was the use of the standard patient to nurse ratios for all ICUs. Even thought the sample consisted of the patients receiving mechanical ventilation and therefore created a hindrance for gathering precise data on staffing levels, the daily bed occupancy rates could have been used to obtain a more precise approximation of nurse to patient ratios. Therefore, this limitation could be overcome in the future studies. The ICUs that had variations in routine staffing levels were assigned the biggest value in a span of 24 hours (Blot et al., 2011). Ethical approvals for the study were issued by the proper government regulatory bodies for each ICU and, considering that it was observational, there was no need for patients’ informed consent (Blot et al., 2011).
The results of the study showed no correlation between high nurse to patient proportion and risk of VAP. Even though the staffing ratio of 1 to 1 was shown to reduce the risk of getting VAP, after data was adjusted for covariates, this result was dismissed. It can be argued that variations between numerous factors such as trauma admissions, duration of risk exposure and severity of the disease can serve as better predictors of VAP (Blot et al., 2011). The authors of the study admitted that their results differed from those obtained by Hugonnet et al. (Blot et al., 2011). According to the findings of the research conducted by Hugonnet et al. in “a single-center cohort” that was considerably bigger than that in the study by Blot et al. there was an association between high nurse to patient ratio and lower risk of VAP occurrence.
The aim of the study was to explore the relationships between staffing levels and rate of VAP incidence. The data from 27 intensive care units was analyzed (Blot et al., 2011). After selection of ICUs that had information on staffing levels, study group consisting of 1658 patients receiving 48 hours of mechanical ventilation was chosen. The units with a variable nurse to patient ratio were ascribed the biggest values (Blot et al., 2011). The results of the study showed that 393 or approximately 24 percent of patients out of the cohort developed VAP (Blot et al., 2011). Without adjustment for confounding variables the proportions of the disease occurrence were as follows: 9.3 percent for 1 to 1 ratio, 25.7 percent for 2 to 1 ratio and 18.7 percent for 3 to 1 ratio (Blot et al., 2011). The readjustment showed that relationships between VAP and staffing levels were not statistically significant.
It can be argued that the article is important to the nursing field because it explores the pressing issue of a nurse to patient ratio. However, it is still too early to reach a conclusion about the necessity to make policy changes considering the numerous limitations of the study. Moreover, the findings of other researches differed from those of the study conducted by Blot et al. calling for further exploration of the issue.
Blot, S., Serra, M., Koulenti, D., Lisboa, T., Deja, M., Myrianthefs, P.,…Rello, J. (2011). Patient to Nurse Ratio and Risk of Ventilator-Associated Pneumonia in Critically Ill Patients. American Journal of Critical Care, 20(1), 1-9.